PLEASURE ISLAND SOCCER ASSOCIATION
Fall 2012 RECREATION LEAGUE Registration
PLAYER NAME: First: Last:
MALE or FEMALE Birth date: / / On Aug. 1, 2012, I will be yrs old and going into Grade.
Uniform Size: Youth Small Youth Med Youth Large Adult Small Adult Med Adult Large
ADDRESS: (City) (zip)
PARENT/GUARDIAN: FIRST: LAST:
Phone Numbers: Home: - - Cell: - -
Best EMAIL address: 2nd EMAIL address:
If possible, I want to be on the same team as Spring 2012. Y or N Team Name or Coach Name:
Waiver of Liability: We/ I, as the parent/legal guardian of the player named above, do hereby declare our intent to allow this child to practice, play,
and participate in all programs and activities associated with the Pleasure Island Soccer Association, including any related activities and
transportation. We/ I hereby release and hold harmless from any and all liability; Pleasure Island Soccer Association, its coaches, sponsors,
associated board members and personnel, officials, or any others associated with this organization against any claim by or on behalf of the player’s
participation in this program.
Medical Consent Release: We/ I do hereby authorize Pleasure Island Soccer Association or any representatives including coaches, officials, or
anyone associated with this organization, if after reasonable attempt has been made to reach the designated parent/guardian named above to
consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray, anesthetic, medical or surgical
diagnosis or treatment or hospital care, to be rendered to the player under the general or special supervision and on the advise of any physician,
dentist or surgeon duly licensed to practice, be indeed rendered to the Registrant
X_____________________________________ X_________________________________________ / /2012
Parent/ legal guardian (Print Name) Parent/ legal guardian (Sign Name) (date)
*I want to COACH my child’s team: ($10 refund if approved). Name: Cell phone# - -
*I want to SPONSOR a team with a tax-deductible donation. (Registration fee is waived for Sponsor’s child) Y or N
SPONSOR FEES: Ages 3 & 4 = $200, All other $250. Pays for uniforms, name on jerseys and your ad on website for the season.
BUSINESS NAME WEB ADDRESS Phone - -
Mail check/money order payable to “PISA”, PO Box 1868, Carolina Beach, NC 28428 by July. 28.
If post-marked after July 28, $10 late fee will apply and will be added to wait list